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• STATE IO NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> l 1 O1 NEN PERMIT ( 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED ( ) 09 DELETE FROM FILE (NO F, <br /> 1 ) 02 CONDITIONAL PERMIT 1 1 06 AMENDED PERMIT ( ) 04 MINOR CHANGE (NO SURCHARGEI <br /> I OWNER <br /> NAME C`PPORATIONI .. VI UAL OR PUBLIC AGEN Y) �, f" PUBLIC AGENCY ONLY <br /> qnma= ( ) 01 FED 1 1 02 STATE ( 1 03 LOCAL , <br /> STREE ,AQDOR SS CITY STATE ZIP <br /> f <br /> cA- <br /> 2 � <br /> II FACILITY <br /> FACI ITY NAME DEALER/FOR VPERVI R <br /> {� <br /> STREET ADDPESS <br /> �� NEAREST CROSS STREET <br /> 02tQ�- �nt.v� r, , <br /> CITY �( <br /> S oc Co <br /> rI_ aOL (.�/�� IIP��20 <br /> MAILING ADDPESS <br /> �a m ST�6{` IIP ��� <br /> PHONE- W,AREA CODE TYPE OF BUSINESS �1L`7L_ <br /> 101 GASOLINE STATION f ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> II 24 H R EME NC NTACT PERSON <br /> DAYS: NAME,LAST NA FIRSTI AND PHONE W/AREA CODE NIM! LAST NAME FIRST) AND PHONE W/AREA CODE <br /> Wry\. 5, Ve-+er5 92r2--/30/ <br /> 9 2 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (l(I 01 TANK ( 7 02 OTHER: CONTAINER NUMBER >;r-/ <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED ( ) UNKNOWN <br /> 0. CONTAINER CAPACITY: /0/&4M GALLONS ( 1 UNKNOWN E. DOES THE CONTAINER STORE: f ) 01 WASTE I\-Y02 PRODUCT <br /> F: DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? OTF 01 YES ( l 02 NO IF YES CHECK APPROPRIATE BOXIEST: <br /> ( ) 01 UNLEADED (Nd-02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL f l 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM 04 UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) Okl 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. 1 1 01 DOUBLE WALLED (10 02 SINGLE WALLED ( ) 03 LINED <br /> D. QNjr01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> ( ) 06 ALUMINUM 1 ) 07 STEEL CLAD f ) 08 BRONZE t ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> f 1 12 UNKNOWN ( 1 13 OTHER: <br /> HSC04-070185 PAGE 1 / <br />